BACKGROUND: A third of endovascularly treated patients with stroke experience incomplete reperfusion (expanded Thrombolysis in Cerebral Infarction [eTICI] <3), and the natural evolution of this incomplete reperfusion remains unknown. We systematically reviewed the literature and performed a meta-analysis on the natural evolution of incomplete reperfusion after endovascular therapy. METHODS: A systematic review of MEDLINE, Embase, and PubMed up until March 1, 2024, using a predefined strategy. Only full-text English-written articles reporting rates of either favorable (ie, delayed reperfusion (DR) or no new infarct) or unfavorable progression (ie, persistent perfusion deficit or new infarct) of incompletely reperfused tissue were included. The primary outcome was the rate of DR and its association with functional independence (modified Rankin Scale score, 0-2) at 90 days postintervention. Pooled odds ratios with 95% CIs were calculated using a random-effects model. RESULTS: Six studies involving 950 patients (50.7% female; median age, 71 years; interquartile range, 60-79) were included. Four studies assessed the evolution of incomplete reperfusion on magnetic resonance imaging perfusion imaging, while 2 studies used diffusion-weighted imaging and noncontrast computed tomography imaging, where new infarct was used to denote unfavorable progression. Five studies defined incomplete reperfusion as eTICI 2b50 or 2c. DR occurred in 41% (interquartile range, 33%-51%) of cases 24 hours postintervention. Achieving DR was associated with a higher likelihood of functional independence at 90 days (odds ratio, 2.5 [95% CI, 1.9-3.4]). CONCLUSIONS: Nearly half of eTICI <3 patients achieve DR, leading to favorable clinical outcomes. This subgroup may derive limited or potentially harmful effects from pursuing additional reperfusion strategies (eg, intra-arterial lytics or secondary thrombectomy). Accurately predicting the evolution of incomplete reperfusion could optimize patient selection for adjunctive reperfusion strategies at the end of an intervention. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT05499832.
- MeSH
- endovaskulární výkony * metody MeSH
- ischemická cévní mozková příhoda * chirurgie diagnostické zobrazování terapie MeSH
- lidé středního věku MeSH
- lidé MeSH
- reperfuze metody MeSH
- senioři MeSH
- trombolytická terapie metody MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- metaanalýza MeSH
- systematický přehled MeSH
BACKGROUND AND OBJECTIVES: Stereotactic radiosurgery (SRS) with neoadjuvant embolization is a treatment strategy for brain arteriovenous malformations (AVMs), especially for those with large nidal volume or concomitant aneurysms. The aim of this study was to assess the effects of pre-SRS embolization in AVMs with an associated intracranial aneurysm (IA). METHODS: The International Radiosurgery Research Foundation AVM database from 1987 to 2018 was retrospectively reviewed. SRS-treated AVMs with IAs were included. Patients were categorized into those treated with upfront embolization (E + SRS) vs stand-alone SRS (SRS). Primary end point was a favorable outcome (AVM obliteration + no permanent radiation-induced changes or post-SRS hemorrhage). Secondary outcomes included AVM obliteration, mortality, follow-up modified Rankin Scale, post-SRS hemorrhage, and radiation-induced changes. RESULTS: Forty four AVM patients with associated IAs were included, of which 23 (52.3%) underwent pre-SRS embolization and 21 (47.7%) SRS only. Significant differences between the E + SRS vs SRS groups were found for AVM maximum diameter (1.5 ± 0.5 vs 1.1 ± 0.4 cm 3 , P = .019) and SRS treatment volume (9.3 ± 8.3 vs 4.3 ± 3.3 cm 3 , P = .025). A favorable outcome was achieved in 45.4% of patients in the E + SRS group and 38.1% in the SRS group ( P = .625). Obliteration rates were comparable (56.5% for E + SRS vs 47.6% for SRS, P = .555), whereas a higher mortality rate was found in the SRS group (19.1% vs 0%, P = .048). After adjusting for AVM maximum diameter, SRS treatment volume, and maximum radiation dose, the likelihood of achieving favorable outcome and AVM obliteration did not differ between groups ( P = .475 and P = .820, respectively). CONCLUSION: The likelihood of a favorable outcome and AVM obliteration after SRS with neoadjuvant embolization in AVMs with concomitant IA seems to be comparable with stand-alone SRS, even after adjusting for AVM volume and SRS maximum dose. However, the increased mortality among the stand-alone SRS group and relatively low risk of embolization-related complications suggest that these patients may benefit from a combined treatment approach.
- MeSH
- dospělí MeSH
- endovaskulární výkony metody MeSH
- intrakraniální aneurysma * terapie MeSH
- intrakraniální arteriovenózní malformace * terapie chirurgie MeSH
- lidé středního věku MeSH
- lidé MeSH
- neoadjuvantní terapie * metody MeSH
- radiochirurgie * metody škodlivé účinky MeSH
- retrospektivní studie MeSH
- senioři MeSH
- terapeutická embolizace * metody MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- srovnávací studie MeSH
BACKGROUND: Recent studies, including the TENSION trial, support the use of endovascular thrombectomy (EVT) in acute ischemic stroke with large infarct (Alberta Stroke Program Early Computed Tomography Score (ASPECTS) 3-5). OBJECTIVE: To evaluate the cost-effectiveness of EVT compared with best medical care (BMC) alone in this population from a German healthcare payer perspective. METHODS: A short-term decision tree and a long-term Markov model (lifetime horizon) were used to compare healthcare costs and quality-adjusted life years (QALYs) between EVT and BMC. The effectiveness of EVT was reflected by the 90-day modified Rankin Scale (mRS) outcome from the TENSION trial. QALYs were based on published mRS-specific health utilities (EQ-5D-3L indices). Long-term healthcare costs were calculated based on insurance data. Costs (reported in 2022 euros) and QALYs were discounted by 3% annually. Cost-effectiveness was assessed using incremental cost-effectiveness ratios (ICERs). Deterministic and probabilistic sensitivity analyses were performed to account for parameter uncertainties. RESULTS: Compared with BMC, EVT yielded higher lifetime incremental costs (€24 257) and effects (1.41 QALYs), resulting in an ICER of €17 158/QALY. The results were robust to parameter variation in sensitivity analyses (eg, 95% probability of cost-effectiveness was achieved at a willingness to pay of >€22 000/QALY). Subgroup analyses indicated that EVT was cost-effective for all ASPECTS subgroups. CONCLUSIONS: EVT for acute ischemic stroke with established large infarct is likely to be cost-effective compared with BMC, assuming that an additional investment of €17 158/QALY is deemed acceptable by the healthcare payer.
- MeSH
- analýza nákladů a výnosů * metody MeSH
- endovaskulární výkony * ekonomika metody MeSH
- ischemická cévní mozková příhoda * ekonomika chirurgie epidemiologie MeSH
- kvalitativně upravené roky života MeSH
- lidé MeSH
- Markovovy řetězce * MeSH
- rozhodovací stromy * MeSH
- senioři MeSH
- trombektomie * ekonomika metody MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- Geografické názvy
- Německo MeSH
BACKGROUND: Open surgery is widely regarded as the standard treatment for spinal dural arteriovenous fistulas (SDAVFs). However, endovascular treatment (EVT) with liquid embolic agents has emerged as an alternative. While N-butyl cyanoacrylate is often preferred for its superior penetration into draining vein, this study aims to assess the effectiveness of an embolization-first strategy using Onyx, drawing on 20 years of clinical experience. METHODS: A retrospective analysis included 50 patients treated between 2004 and 2024. Only patients undergoing EVT as the first-line therapy for SDAVF were included. RESULTS: Overall, EVT achieved complete occlusion in 38 (76%) cases, with an additional 6 (12%) requiring adjuvant surgery resulting in definitive cure. In the remaining 6 (12%) patients, embolization of the feeding artery and fistula nidus led to permanent clinical improvement (n = 4, 66%) or stability (n = 2, 33%), supported by indirect fistula signs regression on follow-up magnetic resonance imaging. Onyx was solely used in 84% of EVTs, achieving a complete occlusion rate of 83%. Clinical improvement or stabilization was observed in 46 (92%) patients, with no recurrences in successfully treated patients. There was no EVT-related complication. Follow-up magnetic resonance imagings showed regression of perimedullary varices and regression or stability of myelopathy in all cases (n = 50, 100%). CONCLUSIONS: The embolization-first strategy, with adjuvant surgery when necessary, can achieve outcomes nearing those of purely surgical approaches. Based on our long-term experience, EVT with Onyx can result in complete and permanent cure of SDAVF in more than 80% of cases.
- MeSH
- cévní malformace centrálního nervového systému * terapie diagnostické zobrazování MeSH
- dimethylsulfoxid * terapeutické užití MeSH
- dospělí MeSH
- endovaskulární výkony metody MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- polyvinyly * terapeutické užití MeSH
- retrospektivní studie MeSH
- senioři MeSH
- tantal * terapeutické užití MeSH
- terapeutická embolizace * metody MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
Background Randomized clinical trials have demonstrated that endovascular thrombectomy reduces functional disability in patients with large ischemic stroke; arterial collateral status might be used to select these patients for endovascular thrombectomy. Purpose To investigate whether arterial collateral status modifies the treatment effect of endovascular thrombectomy in patients with large ischemic stroke. Materials and Methods The Efficacy and Safety of Thrombectomy in Stroke with Extended Lesion and Extended Time Window (TENSION) trial was a prospective, multicenter, randomized study investigating participants with acute large ischemic stroke due to anterior circulation large-vessel occlusion. Participants with an Alberta Stroke Program Early CT Score of 3-5 were enrolled at 41 participating centers between July 2018 and February 2023. Participants were randomly assigned to undergo either endovascular thrombectomy with best medical treatment or best medical treatment alone within 12 hours from stroke onset. Collateral status was graded on pretreatment single-phase CT angiography (CTA) images using the Tan score and dichotomized into poor (grade, 0-1) or good (grade, 2-3) based on the extent of collateral supply filling the affected middle cerebral artery territory. The primary outcome was the shift on the 90-day modified Rankin Scale (mRS). Results Of 253 randomized patients, 201 with pretreatment CTA were included (median age, 74 years; IQR, 66-80 years; 103 [51.2%] female patients; 103 [51.2%] patients underwent endovascular thrombectomy). Endovascular thrombectomy compared with best medical treatment (adjusted common odds ratio [OR], 3.69; 95% CI: 2.12, 6.54; P < .001) and good collaterals compared with poor collaterals (adjusted common OR, 2.88; 95% CI: 1.63, 5.11; P < .001) were independently associated with a shift in the 90-day mRS scores toward better functional outcomes. The treatment effect of endovascular thrombectomy over best medical treatment was not modified by collateral status (interaction, P = .88). The treatment effect of endovascular thrombectomy versus best medical treatment was found in patients with good collaterals (adjusted common OR, 3.93; 95% CI: 1.65, 9.69; P = .002) and poor collaterals (adjusted common OR, 3.92; 95% CI: 1.86, 8.52; P < .001). Conclusion In this secondary analysis of data from the TENSION trial, endovascular thrombectomy reduced 90-day functional disability compared with best medical treatment in patients with good and poor collaterals. These findings suggest that patients with large ischemic stroke manifesting within 12 hours after onset should undergo endovascular thrombectomy irrespective of single-phase CTA collateral status. ClinicalTrials.gov Identifier: NCT03094715 © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Benomar and Raymond in this issue.
- MeSH
- CT angiografie metody MeSH
- endovaskulární výkony * metody MeSH
- ischemická cévní mozková příhoda * diagnostické zobrazování chirurgie terapie MeSH
- kolaterální oběh * MeSH
- lidé středního věku MeSH
- lidé MeSH
- prospektivní studie MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- trombektomie * metody MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- randomizované kontrolované studie MeSH
INTRODUCTION: Acute ischemic stroke (AIS) is the second leading cause of death and one of the leading causes of long-term disability globally. Endovascular thrombectomy (EVT) has revolutionized treatment for large vessel occlusion (LVO), providing 20% increase in post-stroke functional independence compared to intravenous thrombolysis (IVT) alone. Despite its proven efficacy, EVT is underutilized. While it is suitable for at least 15-20% of AIS patients, its mean adoption ranges from less than 1% to 7% in different areas. AREAS COVERED: This review highlights key findings from pivotal randomized controlled trials and real-world data, focusing on patient selection criteria, advancements in thrombectomy devices, and procedural innovations. A comprehensive literature search was performed using PubMed, Scopus, EMBASE and the Cochrane Library for relevant randomized controlled trials and observational studies. EXPERT OPINION: Disparity in access to EVT requires strategic investments in healthcare systems and international multidisciplinary collaboration. Enhancing geographic coverage with thrombectomy-capable centers and optimizing prehospital triage systems are essential. Bridging the gap between treatment capability and real-world implementation is critical to improving global AIS outcomes.
- MeSH
- endovaskulární výkony metody MeSH
- lidé středního věku MeSH
- lidé MeSH
- trombóza nitrolebních žilních splavů * chirurgie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- ženské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH
Mechanická rekanalizace symptomatického uzávěru mozkové tepny je vysoce efektivní a život zachraňující léčbou akutní ischemické CMP. Současná doporučení upravují a rozšiřují národní doporučený postup z roku 2019 na základě recentně publikovaných randomizovaných klinických studií, které prokázaly klinickou účinnost a prospěch MT v léčbě akutního symptomatického uzávěru mozkové tepny i u pacientů s pokročilými ischemickými změnami (Alberta Stroke Program Early CT Score [ASPECTS] 3 až 5 bodů). Doporučení dále zpřesňují indikace pacientů podle časového okna od vzniku příznaků, předcházející soběstačnosti a rovněž rozšiřují možnost indikace rekanalizace u okluze tepen v přední a zadní mozkové cirkulaci. Prezentovaná doporučení pro mechanickou rekanalizaci jsou konsenzuálním stanoviskem výborů Cerebrovaskulární sekce České neurologické společnosti České lékařské společnosti JEP a České společnosti intervenční radiologie České lékařské společnosti JEP.
Mechanical recanalization of symptomatic occlusion of a cerebral artery is a highly effective and life-saving treatment for acute ischemic stroke. The current recommendations update and expand the national guidelines from 2019, based on recently published randomized clinical trials that demonstrated the clinical efficacy and benefits of mechanical thrombectomy in the treatment of acute symptomatic cerebral artery occlusion, even in patients with advanced ischemic changes (ASPECTS scores of 3 to 5). The guidelines further refine patient indications based on the time window from symptom onset, prior functional independence, and also broaden the possibilities for recanalization indications for occlusions of both anterior and posterior cerebral arteries. The presented guidelines for mechanical recanalization represent a consensus statement by the boards of the Cerebrovascular Section of the Czech Neurological Society of the Czech Medical Association JEP and the Czech Society for Interventional Radiology of the Czech Medical Association JEP.
BACKGROUND: Recent randomized trials demonstrated the beneficial effect of endovascular therapy in patients with low Alberta Stroke Program Early CT Score. Despite large follow-up infarct volumes, a significantly increased rate of good functional outcomes was observed, challenging the role of infarct volume as a predictive imaging marker. This analysis evaluates the extent to which the effects of endovascular thrombectomy on functional outcomes are explained by (1) follow-up infarct volume and (2) early neurological status in patients with stroke with low Alberta Stroke Program Early CT Score. METHODS: TENSION (Efficacy and Safety of Thrombectomy in Stroke With Extended Lesion and Extended Time Window) was a randomized trial conducted from February 2018 to January 2023 across 41 stroke centers. Two hundred fifty-three patients with ischemic stroke due to anterior circulation large vessel occlusion and Alberta Stroke Program Early CT Score of 3 to 5 were randomized to endovascular thrombectomy plus medical treatment or medical treatment alone. All patients with the availability of relevant data points were included in this secondary as-treated analysis. The primary outcome was the 90-day modified Rankin Scale score. Confounder-adjusted mediation analysis was performed to quantify the proportion of the treatment effect on a 90-day modified Rankin Scale score explained by (1) 24-hour follow-up infarct volume and (2) 24-hour National Institutes of Health Stroke Scale scores. RESULTS: One hundred eighty-eight patients were included; thereof, 87 (46%) were female patients. Median age was 72 (interquartile range, 63-79) years. The endovascular thrombectomy cohort had a 20.5 (95% CI, 8.3-33.7) percentage points higher probability of achieving independent ambulation (modified Rankin Scale, 0-3) and a 24.2 (95% CI, 13.4-35.8) percentage points lower mortality at 90 days compared with medical treatment alone. The reduction in 24-hour follow-up infarct volume explained 30% of the treatment effect on functional outcomes, while the 24-hour National Institutes of Health Stroke Scale score explained 61%. CONCLUSIONS: In patients with low Alberta Stroke Program Early CT Score, infarct volume demonstrated limited explanatory power for functional outcomes compared with the early neurological status, which may more effectively reflect factors such as the involvement of specific brain regions, disruption of structural networks, and selective neuronal loss.
- MeSH
- endovaskulární výkony metody MeSH
- ischemická cévní mozková příhoda * chirurgie diagnostické zobrazování MeSH
- lidé středního věku MeSH
- lidé MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- trombektomie * metody MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- randomizované kontrolované studie MeSH
